GINA Slideset 2013

GLOBAL INITIATIVE FOR ASTHMA (GINA) TEACHING SLIDE SET
January 2013
This slide set is restricted for academic and educational purposes only. Use of the slide set, or of individual slides, for commercial or promotional purposes requires approval from GINA.
Global Initiative for Asthma
G lobal INitiative for A sthma

GINA Program Objectives

Increase appreciation of asthma as a global public health problem
Present key recommendations for diagnosis and management of asthma Provide strategies to adapt recommendations to varying health needs, services, and resources
Identify areas for future investigation of particular significance to the global community
GINA Structure
Executive Committee
Chair: Mark FitzGerald, MD
Dissemination Committee
Chair: L.B. Boulet, MD
Science Committee
Chair: Helen Reddel, MD
GINA Board of Directors

M. FitzGerald, Chair, Canada E. Bateman, S. Africa P. Paggario, Italy L.P. Boulet, Canada S. Pedersen, Denmark A. Cruz, Brazil H. Reddel, Australia M. Haahtela, Finland M. Soto-Quiroz, Costa Rica M. Levy, U.K. G. Wong, Hong Kong ROC P. OByrne, Canada
GINA Science Committee

H. Reddel, Chair, Australia N. Barnes, UK M. FitzGerald, Canada P. Barnes, UK R. Lemanske, US A. Becker, Canada P. OByrne, Canada E. Bel, Netherlands E. Pizzichini, Brazil J. DeJongste, Netherlands S. Pedersen, Denmark J. Drazen, US H. Reddel, Australia
GINA Structure
Executive Committee
Chair: Mark FitzGerald, MD
Dissemination Committee
Chair: L.P. Boulet, MD
Science Committee
Chair: H. Reddel, MD
GINA ASSEMBLY
GINA Assembly
A network of individuals participating in the dissemination and implementation of asthma management programs at the local, national and regional level GINA Assembly members are invited to meet with the GINA Executive Committee during the ATS and ERS meetings
Slovenia Germany Ireland Yugoslavia Croatia Australia Canada Brazil Austria United States Taiwan Portugal Thailand Philippines Malta Greece Mexico Moldova China Syria Egypt South Africa United Kingdom Hong Kong ROC Chile Italy New Zealand
Lebanon
Saudi Arabia
Bangladesh
Argentina
Venezuela Cambodia Israel Pakistan Japan

Netherlands
Mongolia
Poland Korea
GINA Assembly
Macedonia France
Belgium
Switzerland
Russia
Georgia
Denmark Spain Vietnam
Turkey Czech
India
Slovakia Republic Colombia Ukraine Romania Sweden

Albania
Singapore
Kyrgyzstan
GINA Documents
Global Strategy for Asthma Management and
Prevention (updated 2012)
Pocket Guide: Asthma Management and Prevention

(updated 2012)
Global Strategy for Asthma Management and

Prevention for Children 5 Years and Younger (2009)
Pocket Guide: Asthma Management and Prevention in

Children 5 Years and younger (2009)
Guide for asthma patients and families

All materials are available on GINA web site www.ginasthma.org
Global Strategy for Asthma Management and Prevention

Evidence-based Implementation oriented Diagnosis Management Prevention Outcomes can be evaluated

Evidence Category Sources of Evidence
Randomized clinical trials Rich body of data Randomized clinical trials Limited body of data
A B
C
D
Non-randomized trials Observational studies

Panel judgment consensus
Global Strategy for Asthma Management and Prevention (2012) Definition and Overview Diagnosis and Classification Asthma Medications Asthma Management and Prevention Program Implementation of Asthma Guidelines in Health Systems
Updated 2012
Definition of Asthma
A chronic inflammatory disorder of the airways

Many cells and cellular elements play a role Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing
Widespread, variable, and often reversible airflow limitation

Asthma Inflammation: Cells and Mediators
Source: Peter J. Barnes, MD
Mechanisms: Asthma Inflammation
Asthma Inflammation: Cells and Mediators
Burden of Asthma
Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals Prevalence increasing in many countries, especially in children A major cause of school/work absence
Burden of Asthma

Health care expenditures very high

Developed economies might expect to spend 1-2 percent of total health care expenditures on asthma. Developing economies likely to face increased demand Poorly controlled asthma is expensive; investment in prevention medication likely to yield cost savings in emergency care
Asthma Prevalence and Mortality
Source: Masoli M et al. Allergy 2004
Countries should enter their own data on burden of asthma.
Risk Factors for Asthma
Host factors: predispose individuals to, or protect them from, developing asthma
Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist
Factors that Exacerbate Asthma
Allergens Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs
Factors that Influence Asthma Development and Expression

Host Factors Genetic - Atopy - Airway hyperresponsiveness Gender Obesity Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Diet
Is it Asthma?
Recurrent episodes of wheezing

Troublesome cough at night Cough or wheeze after exercise Cough, wheeze or chest tightness after exposure to airborne allergens or pollutants Colds go to the chest or take more than 10 days to clear
Asthma Diagnosis

History and patterns of symptoms Measurements of lung function - Spirometry - Peak expiratory flow Measurement of airway responsiveness Measurements of allergic status to identify risk factors Extra measures may be required to diagnose asthma in children 5 years and younger and the elderly
Typical Spirometric (FEV1) Tracings

Volume FEV1
Normal Subject
Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)
2 3 4 Time (sec)
Note: Each FEV1 curve represents the highest of three repeat measurements
Measuring Variability of Peak Expiratory Flow
Measuring Airway Responsiveness
Asthma Management and Prevention Program: Five Components

1. Develop Patient/Doctor Partnership 2. Identify and Reduce Exposure to Risk Factors
3. Assess, Treat and Monitor Asthma

4. Manage Asthma Exacerbations
Updated 2012
5. Special Considerations
Asthma Management and Prevention Program
Goals of Long-term Management

Achieve and maintain control of symptoms Maintain normal activity levels, including exercise Maintain pulmonary function as close to normal levels as possible Prevent asthma exacerbations Avoid adverse effects from asthma medications Prevent asthma mortality
Asthma Management and Prevention Program: Five Interrelated Components
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to Risk Factors 3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations 5. Special Considerations
Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms Early intervention to stop exposure to the risk factors that sensitized the airway may help improve the control of asthma and reduce medication needs.
Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control
Part 1: Educate Patients to Develop a Partnership Guidelines on asthma management should be available but adapted and adopted for local use by local asthma planning teams
Clear communication between health care professionals and asthma patients is key to enhancing compliance
Component 1: Develop Patient/Doctor Partnership

Educate continually
Include the family Provide information about asthma Provide training on self-management skills
Emphasize a partnership among health care providers, the patient, and the patients family
Component 1: Develop Patient/Doctor Partnership Key factors to facilitate communication:

Friendly demeanor Interactive dialogue Encouragement and praise Provide appropriate information Feedback and review
Example Of Contents Of An Action Plan To Maintain Asthma Control

Your Regular Treatment: 1. Each day take ___________________________ 2. Before exercise, take _____________________ WHEN TO INCREASE TREATMENT Assess your level of Asthma Control In the past week have you had: Daytime asthma symptoms more than 2 times ? No Yes Activity or exercise limited by asthma? No Yes Waking at night because of asthma? No Yes The need to use your [rescue medication] more than 2 times? No Yes If you are monitoring peak flow, peak flow less than________? No Yes If you answered YES to three or more of these questions, your asthma is uncontrolled and you may need to step up your treatment. HOW TO INCREASE TREATMENT STEP-UP your treatment as follows and assess improvement every day: ____________________________________________ [Write in next treatment step here] Maintain this treatment for _____________ days [specify number] WHEN TO CALL THE DOCTOR/CLINIC. Call your doctor/clinic: _______________ [provide phone numbers] If you dont respond in _________ days [specify number] ______________________________ [optional lines for additional instruction]
EMERGENCY/SEVERE LOSS OF CONTROL If you have severe shortness of breath, and can only speak in short sentences, If you are having a severe attack of asthma and are frightened, If you need your reliever medication more than every 4 hours and are not improving. 1. Take 2 to 4 puffs ___________ [reliever medication] 2. Take ____mg of ____________ [oral glucocorticosteroid] 3. Seek medical help: Go to _____________________; Address___________________ Phone: _______________________ 4. Continue to use your _________[reliever medication] until you are able to get medical help.
Factors Involved in Non-Adherence

Medication Usage
Non-Medication Factors
Difficulties associated with inhalers
Misunderstanding/lack of information Fears about side-effects Inappropriate expectations Underestimation of severity
Complicated regimens
Fears about, or actual side effects Cost Distance to pharmacies
Attitudes toward ill health

Cultural factors Poor communication
Component 2: Identify and Reduce Exposure to Risk Factors

Measures to prevent the development of asthma, and asthma exacerbations by avoiding or reducing exposure to risk factors should be implemented wherever possible. Asthma exacerbations may be caused by a variety of risk factors allergens, viral infections, pollutants and drugs. Reducing exposure to some categories of risk factors improves the control of asthma and reduces medications needs.
Component 2: Identify and Reduce Exposure to Risk Factors
Reduce exposure to indoor allergens

Avoid tobacco smoke Avoid vehicle emission Identify irritants in the workplace Explore role of infections on asthma development, especially in children and young infants
Influenza Vaccination
Influenza vaccination should be provided to patients with asthma when vaccination of the general population is advised However, routine influenza vaccination of children and adults with asthma does not appear to protect them from asthma exacerbations or improve asthma control
Component 3: Assess, Treat and Monitor Asthma The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional
Clinical Control of Asthma

The focus on asthma control is
important because:
the attainment of control correlates with a better quality of life, and reduction in health care use
Clinical Control of Asthma

Determine the initial level of control to implement treatment (assess patient impairment)
Maintain control once treatment has been implemented (assess patient risk)
Levels of Asthma Control

(Assess patient impairment)
Controlled
(All of the following)
Characteristic Daytime symptoms Limitations of activities Nocturnal symptoms / awakening Need for rescue / reliever treatment
Partly controlled
(Any present in any week)
Uncontrolled
Twice or less per week None
More than twice per week Any
None Twice or less per week
Any More than twice per week < 80% predicted or personal best (if known) on any day
3 or more features of partly controlled asthma present in any week
Lung function (PEF or FEV1)
Normal
Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side effects)
Assess Patient Risk

Features that are associated with increased risk of adverse events in the future include:
Poor clinical control

Frequent exacerbations in past year Ever admission to critical care for asthma Low FEV1, exposure to cigarette smoke, high dose medications
Assessment of Future Risk

Risk of exacerbations, instability, rapid decline in lungexacerbation function, side effects Any
should prompt review Features that are associated with increased of maintenance risk of adverse events in the future include: Poor clinical control treatment
Frequent exacerbations in past year Ever admission to critical care for asthma Low FEV1, exposure to cigarette smoke, high dose medications
Component 3: Assess, Treat and Monitor Asthma

Depending on level of asthma control, the patient is assigned to one of five treatment steps Treatment is adjusted in a continuous cycle driven by changes in asthma control status. The cycle involves: - Assessing Asthma Control
- Treating to Achieve Control

- Monitoring to Maintain Control
A stepwise approach to pharmacological therapy is recommended The aim is to accomplish the goals of therapy with the least possible medication Although in many countries traditional methods of healing are used, their efficacy has not yet been established and their use can therefore not be recommended

The choice of treatment should be guided by:

Level of asthma control Current treatment
Pharmacological properties and availability of the various forms of asthma treatment

Economic considerations
Cultural preferences and differing health care systems need to be considered

Controller Medications
Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled 2-agonists in combination with inhaled glucocorticosteroids Systemic glucocorticosteroids Theophylline Cromones Anti-IgE
Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age

Drug
Beclomethasone Budesonide Budesonide-Neb Inhalation Suspension Ciclesonide Flunisolide Fluticasone Mometasone furoate Triamcinolone acetonide 80 160 500-1000 100-250 200-400 400-1000 Low Daily Dose (g) > 5 y Age < 5 y 200-500 200-600 100-200 100-200 250-500 80-160 500-750 100-200 100-200 400-800 >160-320 >1000-2000 >250-500 > 400-800 >1000-2000 Medium Daily Dose (g) > 5 y Age < 5 y >500-1000 600-1000 >200-400 >200-400 500-1000 >160-320 >750-1250 >200-500 >200-400 >800-1200 >320-1280 >2000 >500 >800-1200 >2000 High Daily Dose (g) > 5 y Age < 5 y >1000 >1000 >400 >400 >1000 >320 >1250 >500 >400 >1200
Reliever Medications
Rapid-acting inhaled 2-agonists Systemic glucocorticosteroids Anticholinergics Theophylline Short-acting oral 2-agonists
Component 4: Asthma Management and Prevention Program
Allergen-specific Immunotherapy
Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis The role of specific immunotherapy in asthma is limited Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma Perform only by trained physician
LEVEL OF CONTROL
controlled partly controlled
REDUCE INCREASE
TREATMENT OF ACTION
maintain and find lowest controlling step consider stepping up to gain control
uncontrolled exacerbation
step up until controlled treat as exacerbation
REDUCE
INCREASE
TREATMENT STEPS
STEP STEP STEP STEP STEP
3
TO STEP 3 TREATMENT, SELECT ONE OR MORE:
TO STEP 4 TREATMENT, ADD EITHER
Shaded green - preferred controller options
Treating to Achieve Asthma Control

Step 1 As-needed reliever medication
Patients with occasional daytime symptoms of short duration

A rapid-acting inhaled 2-agonist is the recommended reliever treatment (Evidence A) When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher)

Step 2 Reliever medication plus a single controller A low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages (Evidence A) Alternative controller medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids

Step 3 Reliever medication plus one or two controllers For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled longacting 2-agonist either in a combination inhaler device or as separate components (Evidence A) Inhaled long-acting 2-agonist must not be used as monotherapy For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A)

Additional Step 3 Options for Adolescents and Adults
Increase to medium-dose inhaled glucocorticosteroid (Evidence A) Low-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A) Low-dose sustained-release theophylline (Evidence B)

Step 4 Reliever medication plus two or more controllers
Selection of treatment at Step 4 depends on prior selections at Steps 2 and 3
Where possible, patients not controlled on Step 3 treatments should be referred to a health professional with expertise in the management of asthma

Step 4 Reliever medication plus two or more controllers
Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled 2-agonist (Evidence A) Medium- or high-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A) Low-dose sustained-release theophylline added to medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled 2-agonist (Evidence B)

Step 5 Reliever medication plus additional controller options
Addition of oral glucocorticosteroids to other controller medications may be effective (Evidence D) but is associated with severe side effects (Evidence A) Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications (Evidence A)
Treating to Maintain Asthma Control
When control as been achieved, ongoing monitoring is essential to:

- maintain control
- establish lowest step/dose treatment
Asthma control should be monitored by the health care professional and by the patient

Stepping down treatment when asthma is controlled
When controlled on medium- to high-dose inhaled glucocorticosteroids: 50% dose reduction at 3 month intervals (Evidence B) When controlled on low-dose inhaled glucocorticosteroids: switch to once-daily dosing (Evidence A)

Stepping down treatment when asthma is controlled
When controlled on combination inhaled glucocorticosteroids and long-acting inhaled 2-agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting 2-agonist (Evidence B)
If control is maintained, reduce to lowdose inhaled glucocorticosteroids and stop long-acting 2-agonist (Evidence D)

Stepping up treatment in response to loss of control
Rapid-onset, short-acting or longacting inhaled 2-agonist bronchodilators provide temporary relief. Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy

Stepping up treatment in response to loss of control
Use of a combination rapid and long-acting inhaled 2-agonist (e.g., formoterol) and an inhaled glucocorticosteroid (e.g., budesonide) in a single inhaler both as a controller and reliever is effecting in maintaining a high level of asthma control and reduces exacerbations (Evidence A) Doubling the dose of inhaled glucocorticosteroids is not effective, and is not recommended (Evidence A)
Component 4: Manage Asthma Exacerbations

Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness
Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)
Severe exacerbations are potentially lifethreatening and treatment requires close supervision
Component 4: Manage Asthma Exacerbations Treatment of exacerbations depends on: The patient Experience of the health care professional Therapies that are the most effective for the particular patient Availability of medications Emergency facilities
Component 4: Manage Asthma Exacerbations

Primary therapies for exacerbations:
Repetitive administration of rapid-acting inhaled 2-agonist Early introduction of systemic glucocorticosteroids Oxygen supplementation
Closely monitor response to treatment with serial measures of lung function

Special Considerations
Special considerations are required to manage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma
Global Strategy for the Diagnosis and Management of Asthma in Children 5 Years and Younger 2009
www.ginasthma.org
Asthma Management and Prevention Program: Summary
Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms
Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control
Asthma Management and Prevention Program: Summary A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered
http://www.ginasthma.org

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GLOBAL INITIATIVE FOR ASTHMA (GINA) TEACHING SLIDE SET

Global Initiative for Asthma

G lobal INitiative for A sthma

GINA Program Objectives

Global Initiative for Asthma

GINA Board of Directors

GINA Science Committee

Venezuela Cambodia Israel Pakistan Japan

Slovakia Republic Colombia Ukraine Romania Sweden

Pocket Guide: Asthma Management and Prevention

Global Strategy for Asthma Management and

Pocket Guide: Asthma Management and Prevention in

Guide for asthma patients and families

Global Strategy for Asthma Management and Prevention

Global Strategy for Asthma Management and Prevention

Non-randomized trials Observational studies

Global Initiative for Asthma

A chronic inflammatory disorder of the airways

Widespread, variable, and often reversible airflow limitation

Asthma Inflammation: Cells and Mediators

Source: Peter J. Barnes, MD

Mechanisms: Asthma Inflammation

Source: Peter J. Barnes, MD

Asthma Inflammation: Cells and Mediators

Source: Peter J. Barnes, MD

Health care expenditures very high

Asthma Prevalence and Mortality

Source: Masoli M et al. Allergy 2004

Countries should enter their own data on burden of asthma.

Risk Factors for Asthma

Global Initiative for Asthma

Factors that Exacerbate Asthma

Factors that Influence Asthma Development and Expression

Global Initiative for Asthma

Recurrent episodes of wheezing

Typical Spirometric (FEV1) Tracings

Asthmatic (After Bronchodilator)

Asthmatic (Before Bronchodilator)

Measuring Variability of Peak Expiratory Flow

Measuring Airway Responsiveness

Global Initiative for Asthma

Asthma Management and Prevention Program: Five Components

3. Assess, Treat and Monitor Asthma

Asthma Management and Prevention Program

Goals of Long-term Management

Global Initiative for Asthma

Asthma Management and Prevention Program: Five Interrelated Components

1. Develop Patient/Doctor Partnership

Asthma Management and Prevention Program

Asthma Management and Prevention Program

Global Initiative for Asthma

Asthma Management and Prevention Program

Asthma Management and Prevention Program

Component 1: Develop Patient/Doctor Partnership

Asthma Management and Prevention Program

Component 1: Develop Patient/Doctor Partnership Key factors to facilitate communication:

Example Of Contents Of An Action Plan To Maintain Asthma Control

Global Initiative for Asthma

Asthma Management and Prevention Program

Factors Involved in Non-Adherence

Difficulties associated with inhalers

Misunderstanding/lack of information Fears about side-effects Inappropriate expectations Underestimation of severity

Attitudes toward ill health

Global Initiative for Asthma